Negative lymph node count as an independent prognostic factor in stage III patients after curative gastrectomy: A retrospective cohort study based on a multicenter database

Challenging the Dogma: Stage migration or negative lymph nodes, which of them is the main player on gastric cancer prognosis?

Expanding loco-regional nodes harvesting is expected to increase survival. This improvement may be associated to stage migration (SM). However, the great bulk of harvested lymph nodes observed in large dissections is negative. M&M: 830 patients who received R0 gastrectomy for adenocarcinoma were included. pN+ patients with <26 nodes (n = 209) were included for a simulation to "offer 26 nodes" - SM (proportional and exponential based) was simulated and analysed through machine learning algorithms. Overall Survival (OS), in native and simulated stages, were compared. OS of extended lymphadenectomies (pN+, D ≥ 26, n = 273) was compared with the simulated curves. OS of patients in the following dissection intervals of negative nodes were compared: <16 (n = 233), 16-25 (n = 258), ≥26 (n = 339). RESULTS: After simulation to 26 nodes (pN+, D < 26 patients, n = 209), staging was recomputed. OS of native vs simulated early-stages (I-II) and advanced stages (III) were not different (p > 0.05). OS of patients with lymphadenectomy (≥26) was better than simulated for early and advanced stages (p = 0.008; p = 0.005). OS of patients included in distinct intervals of negative lymph nodes were different (p < 0.001). These intervals were an independent prognostic factor (multivariate analysis). CONCLUSIONS: The influence of Stage Migration was null in this set of simulations and Will Rogers phenomenon was not observed. Extended dissection performed better in OS. But the influence of the number of negative nodes, even in large dissections, was highlighted. By emphasizing the role of negative nodes, we aim to facilitate more informed decision-making in management of gastric cancer patients, ultimately leading to improved treatment outcomes and patient care.

Revolutionizing T3-4N0-2M0 gastric cancer staging with an innovative pathologic N classification system

BACKGROUND

The current pathologic N (pN) classification exhibits limitations in the prognostic stratification of patients with pT3-4N0-2M0 gastric cancer (GC). Therefore, this study aimed to develop and validate a new lymph nodal staging method based on the number of examined lymph nodes (ELNs) and lymph node ratio (LNR).

METHODS

Data from 7883 patients with pT3-4N0-2M0 GC were collected from the Surveillance, Epidemiology, and End Results (SEER) database and Zhejiang Cancer Provincial Hospital. Optimal cutoff values for ELNs and LNR were determined using X-tile software. Kaplan-Meier methods, Log-rank tests, and Cox regression analyses were employed in this study. Patients were categorized into 3 new pN stages: new pN0 (pN0 with ELNs of >16), new pN1 (pN0 with ELNs of ≤16 or pN1-2 with LNR of ≤0.15), and new pN2 (pN1-2 with LNR of >0.15). The prognostic predictive power of both current and new pN staging was evaluated using the Akaike information criterion (AIC), Bayesian information criterion, concordance index (C-index), and receiver operating characteristic curve.

RESULTS

The new pN classification exhibited excellent performance in Kaplan-Meier survival analysis. After adjusting for confounding factors, the new pN staging emerged as an independent prognostic indicator in patients with GC. In the SEER cohort, the new pN staging demonstrated enhanced prognostic prediction accuracy over the American Joint Committee on Cancer pN staging (AIC: 75578.85 vs 75755.06; C-index: 0.642 vs 0.630; P < .001). Similar findings were validated in the Chinese cohort.

CONCLUSION

This study developed and validated an improved pN classification for patients with pT3-4N0-2M0 GC. Surgeons should consider ELNs and LNR when assessing postoperative prognosis in patients with GC.

Combination of the Ratio Between Negative and Harvested Lymph Nodes and Metastatic Lymph Node Count as a Prognostic Indicator in Stage III Colon Cancer: A Retrospective Cohort Study

BACKGROUND

This study aimed to investigate the relationship between the ratio of negative lymph nodes (NLN) number to the number of metastatic lymph nodes (MLN) and the harvested lymph nodes (HLN) number ratio survival rate and compare its prognostic value.

METHODS

This retrospective cohort study included 207 stage III colon cancer patients between 2010 and 2018 at a single center. NLN/MLN and NLN/HLN cut-off values were determined with the receiver operating characteristic (ROC) curve according to 5-year survival. The patients were divided into high-risk and low-risk groups according to the cut-off value. These 2 groups were evaluated according to the clinicopathological data of the patients.

RESULT

The time-dependent ROC curve showed the optimal cut-off values of NLN as 3.86 and .79, respectively. These values show 83 patients in the high-risk group and 124 in the low-risk group. There was no difference between the groups in tumor localization and T stage. According to Kaplan-Meier survival analysis, mean survival was 35.88 months in the high-risk group and 50.18 months in the low-risk group. The risk of death in the high-risk group was 305% compared to the low-risk group (Hazard Ratio: 3.05, 95% 1.91 - 4.88) (P < .001).

CONCLUSION

NLNs are among the critical prognostic factors in colon cancer. Although NLNs have a positive correlation with the survival rate of the patients, there is no statistical difference in tumor T stage and localization.

Prognostic role of the number of resected and negative lymph nodes in Spanish patients with gastric cancer

INTRODUCTION

Lymph node (LN) involvement is one of the most critical prognostic factors in resected gastric cancer (GC). Some analyses, mainly conducted in Asian populations, have found that patients with a higher number of total lymph nodes (NTLN) and/or negative lymph nodes (NNLN) have a better prognosis, although other authors have failed to confirm these results.

MATERIALS AND METHODS

Retrospective study including all patients with GC resected in a tertiary hospital in Spain between 2001 and 2019 (n = 315). Clinicopathological features were collected and patients were categorized according to the NTLN and the NNLN. Statistical analyses were performed.

RESULTS

Mean NNLN was 17. The NNLN was significantly related to multiple clinicopathological variables, including recurrence and tumor-related death. The classification based on the NNLN (N1: ≥16, N2: 8-15, N3: ≤7) effectively stratified the entire cohort into three distinct prognostic groups and maintained its prognostic value within both the pN0 and pN+ patient subsets. Furthermore, it was an independent prognostic indicator for both overall and disease-free survival. Conversely, the mean NTLN was 21.9. Patients with ≤16 LN retrieved exhibited distinct clinicopathological features compared to those with >16 LN, but no significant differences were observed in terms of recurrence or disease-associated death. The application of alternative cut-off points for NTLN (10, 20, 25, 30, and 40) showed no prognostic significance.

CONCLUSIONS

In Spanish patients with resected GC the NNLN hold prognostic significance, while the NTLN does not appear to be prognostically significant. Incorporating the NNLN into GC staging may enhance the accuracy of the TNM system.

Negative Lymph Node Is an Independent Prognostic Factor for Stage III Gastric Cancer Patients After Curative Gastrectomy: A Surveillance, Epidemiology, and End Results-Based Study

BACKGROUND

Negative lymph node (NLN)' s prognostic impact on stage III gastric cancer (GC) patients after curative gastrectomy has not been rigorously studied. We aimed to explore the relationship between NLNs count and outcomes of stage III GC patients.

METHODS

We retrospectively investigated stage III gastric cancer cases between 2008 and 2018 from Surveillance, Epidemiology, and End Results (SEER) database. Variables were compared by chi2 test. Kaplan-Meier methods and COX proportional hazard models were used to ascertain independent prognostic factors. Survival differences among the subgroups were analyzed to assess the effects of NLN count on overall survival (OS) in stage III GC patients.

RESULTS

2373 patients with curative gastrectomy for stage III GC were identified. Univariate analysis demonstrated that NLNs count >14 was associated better 5-year OS (43.7% VS 23.1%, P< .001) comparing with the NLNs count ≤ 14. Subgroup analysis showed that the NLNs count could predict survival in both node-negative and node-positive patients. Multivariate analysis revealed NLNs count is an independent prognostic factor.

CONCLUSIONS

The NLNs count is an independent prognostic factor for survival in stage III gastric cancer patients after curative gastrectomy and should be recommended for clinical applications.

Short-term and long-term outcomes of patients with gastric cancer during versus before the COVID-19 pandemic: cohort study using propensity score matching method

BACKGROUND

The negative effects of the novel coronavirus disease 2019 (COVID-19) pandemic on patients with gastric cancer are poorly understood. This study was designed to compare the short-term and long-term outcomes of patients with gastric cancer in the same period before and during the COVID-19 pandemic.

METHODS

We retrospectively collected consecutive patients with definite diagnosis of gastric cancer at our center between 1 January and 30 June of 2019 (Before COVID-19) and 2020 (During COVID-19). A comparison was made between the number of patients and their characteristics before and during the COVID-19 epidemic. Propensity score matching (PSM) at 1:1 ratio was performed to evaluate the outcomes of patients that underwent laparoscopic radical gastrectomy in two groups.

RESULT

The total number of patients diagnosed with gastric cancer during the COVID-19 pandemic increased by 21.4%, compared to that before the COVID-19 pandemic. AII the qualified patients were divided Before COVID-19 Pandemic group (BCP n = 99) and During COVID-19 Pandemic group (DCP n = 118). PSM yielded 81 patients with comparable baseline characteristics into each group. Compared to the BCP group, the DCP group had longer surgery time(P = 0.011), more blood loss(P = 0.015), longer postoperative hospital stay(P = 0.002). No statistical differences were observed in terms of type of resection, number of retrieved lymph nodes (LNs), pathology, short-term and long-term complications (P > 0.05).

CONCLUSION

Patients diagnosed with gastric cancer during the COVID-19 pandemic had comparable short-term outcomes and long-term complications, but worse peri-operative outcomes, compared to that before the COVID-19 pandemic. Further research is needed to investigate long-term outcomes.

Impact of HER2 on prognosis and benefit from adjuvant chemotherapy in stage II/III gastric cancer patients: a multicenter observational study

BACKGROUND

Human epidermal growth factor receptor 2 (HER2) is a well-developed therapeutic target in breast and gastric cancer (GC). However, the impact of HER2 on survival and benefit from fluorouracil-based adjuvant chemotherapy remains unclear in patients with GC.

MATERIALS AND METHODS

This multicenter cohort study involved 5622 consecutive stage II/III GC patients. HER2 expression was assessed prospectively via immunohistochemistry (IHC). The staining intensity was graded on a scale of 0 to 3+. An IHC score of 2+or 3+was defined as high expression, and a score of 3+was defined as overexpression.

RESULTS

HER2 overexpression was independently associated with a lower 5-year overall survival (OS) in stage II [hazard ratio (HR), 2.10; 95% CI: 1.41-3.11], but not in stage III GC (HR, 1.00; 95% CI, 0.82-1.20). Further analysis revealed that stage II patients with high HER2 expression showed a poorer response to chemotherapy than stage II patients with low HER2 expression ( Pinteraction =0.024). The HRs for 5-year OS were 0.51 (95% CI, 0.38-0.70) for stage II patients with low HER2 expression, 0.58 (95% CI, 0.51-0.66) for stage III patients with low HER2 expression, 1.13 (95% CI, 0.61-2.09) for stage II patients with high HER2 expression, and 0.47 (95% CI, 0.36-0.61) for stage III patients with high HER2 expression.

CONCLUSIONS

Fluorouracil-based adjuvant chemotherapy is insufficient for stage II GC patients with high HER2 expression, indicating that prospective trials are required to validate alternative HER2-targeted adjuvant therapies in the individuals above.

Examined lymph node count for gastric cancer patients after curative surgery

Lymph node (LN) metastasis is the most common form of metastasis in gastric cancer (GC). The status and stage of LN metastasis are important indicators that reflect the progress of GC. The number of LN metastases is still the most effective index to evaluate the prognosis of patients in all stages of LN metastasis. Examined LN (ELN) count refers to the number of LNs harvested from specimens by curative gastrectomy for pathological examination. This review summarizes the factors that influence ELN count, including individual and tumor factors, intraoperative dissection factors, postoperative sorting factors, and pathological examination factors. Different ELN counts will lead to prognosis-related stage migration. Fine LN sorting and regional LN sorting are the two most important LN sorting technologies. The most direct and effective way to harvest a large number of LNs is for surgeons to perform in vitro fine LN sorting.

Safety and Efficacy of Carbon Nanoparticle-Labeled Lymph Node Dissection in Radical Resection of Gastric Cancer: A Systematic Review and Meta-Analysis

Objective: In this meta-analysis, we investigated the safety and efficacy of carbon nanoparticle (CNP) trace-guided lymph node (LN) dissection during radical gastrectomy. Methods: Literature on CNP tracing compared with non-CNP tracing in radical gastric cancer (GC) surgery was searched from PubMed, EMBASE (Ovid platform), Web of Science, and the Cochrane Library from the establishment of the library until October 2022. This meta-analysis was performed according to the preferred reporting items for systematic reviews and meta-analysis guidelines. Available data regarding the number of LNs dissected, number of metastatic LNs dissected, other surgical outcomes, and postoperative complications were analyzed in a pooled manner. Stata software (version 12.0) was used for the present meta-analysis. Results: This analysis included 7 studies with a total of 1827 GC patients (551 and 1276 in the CNP and non-CNP groups, respectively). The results of the meta-analysis showed that the CNP group had more intraoperative LNs detected [weighted mean difference (WMD) = 6.67, 95% confidence interval (CI): 3.71-9.62], more LN metastases (WMD = 1.60, 95% CI: 0.09-3.12), and less intraoperative bleeding (WMD = 11.33, 95% CI: 6.30-16.37) than the non-CNP group, all with statistically significant differences (P < .05). For postoperative complications (odds ratio [OR] = 0.88, 95% CI: 0.52-1.48) and operative time (WMD = -11.60, 95% CI: -40.53-17.34), there was no statistically significant difference between the 2 groups (P > 0.05). Conclusions: CNP was a significant tracer for the LNs of GC. It increased the number of LNs harvested while reducing intraoperative blood loss, without increasing the operative time or postoperative complications. CNP tracer-guided lymphadenectomy is considered safe and effective for gastrectomy.

Safety and efficacy of indocyanine green near-infrared fluorescent imaging-guided lymph nodes dissection during radical gastrectomy for gastric cancer: A systematic review and meta-analysis

Background

Indocyanine green (ICG) fluorescence imaging has been a new surgical navigation technique for gastric cancer. However, its clinical value should still be evaluated further. In this meta-analysis, we investigated the safety and efficacy of ICG near-infrared fluorescent imaging-guided lymph nodes (LNs) dissection during radical gastrectomy.

Methods

Studies comparing ICG fluorescence imaging with standard care in patients with gastric cancer were systematically searched from PubMed, Embase, Web of Science, and Cochrane Library through August 2021. The current meta-analysis was performed according to the preferred reporting items for systematic review and meta-analysis guidelines. A pooled analysis was performed for the available data regarding the number of LNs dissection, the number of metastatic LNs dissection, other operative outcomes, and postoperative complications. R software version 4.2.0 and Stata 16.0 software were used for the present meta-analysis.

Results

This analysis included 12 studies with a total of 1365 gastric cancer patients (569 in the ICG group and 796 in the non-ICG group). The number of retrieved LNs in the ICG group was significantly higher (weighted mean difference [WMD]=7.67, 95% confidence intervals [CI]: 4.73 to 10.62, P&lt;0.05) compared to the non-ICG group with moderate heterogeneity (P&lt;0.001, I2 = 70%). The number of metastatic LNs, operative time, and postoperative complications were all comparable and without significant heterogeneity. Additionally, ICG near-infrared fluorescent imaging was associated with reduced intraoperative blood loss (WMD=-10.28, 95% CI: -15.22 to -5.35, P&lt;0.05) with low heterogeneity (P=0.07, I2 = 43%).

Conclusions

ICG near-infrared fluorescent imaging-guided lymphadenectomy was considered to be safe and effective in gastrectomy. ICG was used to increase the number of LNs harvested while reducing intraoperative blood loss without increasing operative time or postoperative complications.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021291863.

Combination of the ratio between metastatic and harvested lymph nodes and negative lymph node count as a prognostic indicator in advanced gastric cancer: a retrospective cohort study

Background

The aim of our study was to examine the impact of the combination of the ratio between metastatic and harvested lymph nodes (RML) and negative lymph node (NLN) count on overall survival (OS) in patients with advanced gastric cancer (GC).

Methods

The clinicopathological data of 2,952 advanced GC patients who received curative resection between 1994 and 2015 were collected. They were divided into four groups according to the RML: 0, 0-0.1, 0.1-0.4, and >0.4. We distinguished survival differences through Kaplan-Meier analysis among the subgroups to investigate the impacts of the RML on OS in advanced GC patients. OS was examined according to clinicopathological variables. Spearman's correlation coefficient was used to assess the relationships between the RML and metastatic lymph node (MLN) count and NLN count.

Results

A total of 1,182 patients were enrolled into the study. The median follow-up time was 39 months (interquartile range 20 to 68 months). The 5-year OS rate of all 1,182 GC patients was 54.4%. Kaplan-Meier survival analysis showed that the median OS declined significantly with increasing RML (5-year survival rate 81.2% vs. 69.1% vs. 42.8% vs. 13.1%, P<0.001). As the NLN count increased, the survival rate of GC patients increased (5-year survival rate 12.8% vs. 25.2% vs. 60.2%, P<0.05). The RML, not NLN count, was identified as an independent factor for OS (P<0.001) through multivariate analysis. Spearman correlation analysis suggested that the RML was positively correlated with the number of MLNs (ρ=0.973, P<0.001) and inversely associated with the NLN count (ρ=-0.513, P<0.001).

Conclusions

The RML is an independent prognostic predictor of OS in advanced GC patients, and the NLN count may serve as a supplementary strategy for the present tumor-node-metastasis (TNM) classification to further improve the prognostic prediction efficiency. The combination of the RML and NLN count should be an important predictor for current clinical applications.

Aorta Calcification Increases the Risk of Anastomotic Leakage After Gastrectomy in Gastric Cancer Patients

Purpose

The purpose of the present study was to evaluate whether vascular calcification is a risk factor for anastomotic leakage after gastrectomy in gastric cancer patients.

Methods

Patients with confirmed gastric cancer were collected from the database of a single clinical center from January 2013 to January 2019. The calcification score and anastomotic leakage were recorded, and predictors of anastomotic leakage were analyzed.

Results

A total of 856 patients were included in this study; 818 patients had no anastomotic leakage, and 38 patients had anastomotic leakage. The ratio of hypertension status (p=0.011), open gastrectomy (p=0.012), postoperative length of stay (p=0.000), aorta calcification score (p=0.000) and celiac axis calcification (p=0.000) were higher in the anastomotic leakage group than in the nonanastomotic leakage group. In multivariate analysis, aorta calcification (p=0.029, odds ratio =2.425, 95% CI=1.095–5.491) was an independent predictor of the anastomotic leakage.

Conclusion

Aorta calcification is an independent risk factor for anastomotic leakage after gastrectomy in gastric cancer patients.

Ratio between negative and positive lymph nodes is a novel prognostic indicator for patients with esophageal cancer: A Surveillance, Epidemiology and End Results database analysis

Background

The aim of this study was to explore whether the ratio between negative and positive lymph nodes (R_NP) could predict the overall survival (OS) of esophageal cancer (EC) patients with lymph node metastasis following esophagectomy.

Methods

We utilized the Surveillance, Epidemiology and End Results (SEER) database to include the records of 2374 patients with lymph node metastases post‐surgery. All patients were randomly assigned into the training cohort (n = 1424) and validation cohort (n = 950). Multivariate Cox regression analyses were performed to identify independent prognostic factors. A novel R_NP ‐based TR_NPM staging system was proposed. The prognostic value of N, R_NP, TNM and TR_NPM staging system was evaluated using the linear trend χ² test, likelihood ratio χ² test, and Akaike information criterion (AIC) to determine the potential superiorities. We constructed nomograms to predict survival in both cohorts, and the calibration curves confirmed the predictive ability.

Results

Univariate analyses showed that N and R_NP stage significantly influenced the OS of patients. Multivariate analyses revealed that R_NP was an independent prognostic predictor in both the training and validation cohorts. For the stratification analysis in the two cohorts, we found significant differences in the prognosis of patients in different R_NP groups on the basis of the different N stages and the number of dissected lymph nodes. In addition, the lower AIC value of R_NP stage and TR_NPM staging system represented superior predictive accuracy for OS than the N stage and TNM staging system, respectively. Furthermore, the calibration curves for the probability of three‐ and five‐year survival showed good consistency between nomogram predictive abilities and actual observation.

Conclusions

We demonstrated that compared to the classical pathological lymph nodal staging system, the R_NP stage showed superior predictive accuracy for OS and can serve as a more effective prognostic guidance for lymph node positive EC patients.